RESEARCH ARTICLE Open Access

“It has to be fixed”: a qualitative inquiryinto perceived ADHD behaviour amongaffected individuals and parents in WesternAustraliaManonita Ghosh1*, Colleen Fisher2, David B. Preen1 and C. D’Arcy J. Holman1

Abstract

Background: The use of stimulant medication for Attention Deficit Hyperactivity Disorder (ADHD) to improve classroombehaviour and sustained concentration is well known. Achieving a better academic grade has been reported as theprime motivation for stimulant use and is an increasingly discussed topic. The proliferation of stimulant use for ADHDhas been a cause for public, medical and policy concern in Australia. This paper explores individuals’ perceptions ofADHD, the meaning that the diagnosis carries for them and their attitudes to stimulant medication treatment.

Methods: This qualitative study was underpinned by a social constructivist approach and involved semi-structuredinterviews with eight participants. The participants were parents of children with ADHD or were adults who themselveshad been diagnosed with ADHD. Interviews were audiotaped, transcribed verbatim and thematically analysed.

Results: There were three interrelated yet contradictory overarching themes: (i) An impairment to achieving success,which can be a double-edged sword, but has to be fixed; (ii) Diagnosis as a relief that alleviates fault and acknowledgesfamilial inheritance; (iii) Responsibility to be normal and to fit in with societal expectations. Collectively, these perceptionsand meanings were powerful drivers of stimulant use.

Conclusions: Paying attention to perceptions of ADHD and reasons for seeking or not seeking stimulant treatment isimportant when planning appropriate interventions for this condition.

Keywords: ADHD, Stimulant medication, Qualitative study, Social constructivism, Thematic analysis

BackgroundAttention Deficit Hyperactivity Disorder (ADHD) isdefined as a chronic neuro-developmental disorder char-acterised by the core symptoms of hyperactivity, impul-sivity and inattention [1]. It affects more than 7 % ofchildren [2] with a higher prevalence among boys [3].There has, however, been considerable argument sur-rounding the aetiology of ADHD, questioning whether itis a neuro-genetic condition or a socially constructedillness [4]. The debate is fuelled in part by the general ifnot ambiguous nature of ADHD symptoms defined in

the DSM-V [1]. Some argue that children often displaybehavioural characteristics that include features analo-gous to the symptoms of ADHD, such as hyperactivityand inattentiveness [5]. Additionally, the treatment ofADHD with psychostimulant medication has been con-troversial and the focus of much debate in developedcountries including Australia, due to the subjectivity ofthe diagnosis as well as the ethics of treating childrenlong-term with substances that have the potential forabuse [6, 7]. Much attention has also been paid to theshort and long-term effects of stimulant use includingthe risk of cardiovascular complications [8].Prescriptions for simulant medication have risen sharply

in Western countries over the last decade [9–11]. InAustralia, the rate of stimulant treatment rose 72 %between 2000 and 2011 [12], representing an average

* Correspondence: manonita.ghosh@uwa.edu.au1Centre for Health Services Research, School of Population Health, TheUniversity of Western Australia, 35 Stirling Highway, Crawley, WA 6009,AustraliaFull list of author information is available at the end of the article

© 2016 Ghosh et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Ghosh et al. BMC Health Services Research (2016) 16:141 DOI 10.1186/s12913-016-1399-1

annual growth of 4.7 % and exceeding estimated growthrates in the US by 1–2 % [13]. The persistent rise reflectswidening diagnostic criteria [14], an increase in studiespurporting benefits from early recognition of ADHD andthe efficacy of stimulant medications [15], effective mar-keting by pharmaceutical companies and a greater accept-ance of stimulant treatment among health professionals[16]. This proliferation of stimulant treatment has beencause for public concern that too many children are diag-nosed with ADHD and treated with stimulant medicationswhen they do not actually have a disorder [17]. The stimu-lant medications that are recommended by AmericanAcademy of Paediatrics [18] may lessen the severity ofADHD symptoms, increase attention and concentration,and improve classroom behaviour [19]. However, it hasbeen noted that short-term stimulant treatment showingimprovement in childhood does not necessarily have last-ing effects into the adolescent years [20]. Further, themedications do not promote learning or improve cogni-tive ability [21]. Nevertheless, it has been reported thatthey are used for the purpose of neurocognitive enhance-ment [6]. Parents are more likely to adhere to stimulanttreatment if their child has a cognitive impairment [22].Achieving better academic grades and enhancing cognitiveperformance is reported to have been the prime motiv-ation for stimulant use among asymptomatic students,who feigned the features of ADHD in order to obtainprescriptions [23].In light of polarised debate, yet increasing use of stimu-

lant treatment, individuals’ perceptions and experiencesrelated to their child’s or their own diagnosis and treat-ment are important, but have largely been ignored. Tayloret al. [24] suggested that parents’ decisions to administerpsychostimulant treatment are based on their own blendof personal experience, observations of societal norms andmedia reports. Understanding individuals’ perceptions ofand attitudes towards stimulant treatment is importantfor appropriate intervention and proper management. Un-derstanding which members of the community are morewilling to accept stimulant treatment and the factors thatmake stimulant use more acceptable would be helpful toavoid over-diagnosis and overtreatment.This study used a qualitative approach to understand

how parents of children diagnosed with ADHD, as wellas adults diagnosed with ADHD perceived ADHD be-haviour and stimulant treatment. The objectives of thisstudy were to explore individuals’ perceptions of ADHDbehaviour, the meaning that the diagnosis carries forthem, and their attitudes to stimulant treatment derivedfrom their everyday experiences.

MethodsThe qualitative approach used for this research was under-pinned by a social constructivist philosophical stance,

which emphasized the way individuals seek to understandtheir world and construct their own particular meaningsthat correspond to their experiences [25]. It assumes thatknowledge and truths are created by the individual’s every-day interactions [26]. Constructivism therefore assisted inthe understanding of how the participants in this studyperceived ADHD behaviour and stimulant treatment.

SampleParticipants were recruited through volunteer sampling.An information sheet was distributed to primaryschools, Department of Health Western Australia (WA)facilities, and the Learning and Attentional DisorderSociety Support Groups in WA. A snowball technique inwhich participants were contacted via networks was alsoemployed [27]. Participants were selected based on thefollowing criteria [28]: those who themselves were diag-nosed or had dependent children diagnosed with ADHD;aged over 18 years; and were able to converse fluently inEnglish. We received expressions of interest to participatein this study from ten people with similar ethnic andsocioeconomic backgrounds. Data saturation was reachedafter collecting information from eight participants as nofurther new themes emerged from the analysis [29]. Theparticipants were aged 30–60 years, seven of whom werefemale and all were English speaking and resided in thePerth metropolitan area (see Table 1). The sample com-prised six parents of children with ADHD (aged 3–23years), one grandmother of an ADHD child aged 17 yearsand one childless adult diagnosed with ADHD and depres-sion. Four parents had more than one child diagnosed withADHD. Three parents were also diagnosed with ADHD atages 40–45 years and another two were diagnosed withdepression. All participants described their race asCaucasian with five born in Australia and three born in theUS, UK and South Africa respectively. Of those bornoverseas, two had been living in Australia for 22–26 yearsand the third immigrated 5 years ago prior to starting afamily. They all had university degrees, five were profes-sionals, two were stay-home parents and one was a student.

Data collection procedureIn order to understand the individuals’ perceptionstowards ADHD behaviour, after obtaining signed con-sent to participate, semi-structured face-to-face in-depthinterviews were conducted to capture participant beliefsand thoughts in their own words [30]. Seven key ques-tions guided the interview sessions were (See Additionalfile 1 for demographic and interview questions):

1. How was the decision made to seek for professionalhelp?

2. How did you feel being/your child being diagnosedwith ADHD?

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3. Who do you think is responsible for this condition(ADHD)? Why

4. How was the decision made to administermedication?

5. How do you feel about administering medication forADHD?

6. How was your/child’s behaviour and your decisionto administer medication received by your familyand friends?

7. How did their response make you feel? How did youwant them to make you feel?

The semi-structured interview kept the discussion ontrack within the available time restraints. Each interviewlasted approximately one hour. This was long enough toencourage participants to talk freely, but not too long totire them. To keep all interviews consistently focussed

yet uninhibited, each participant was asked the samequestions, but with a change in the order of questions asappropriate to maintain the flow of the interview. Add-itional open ended questions were used as prompts, de-pending on the nature of the discussion. With eachparticipant’s permission all interviews were audio-recorded. The interviews took place at participants’homes or at other alternative participant-nominatedlocations to allow them to retain some control overthe interview situation and to render the interviewsession non-threatening, comfortable and convenientfor them [31].

Data analysisThematic analysis of participants’ transcribed interviewswas conducted. Thematic analysis is a qualitative“method for identifying, analysing and reporting patterns(themes) within data” [32] (P. 79). Thematic analysis isappropriate for exploring and understanding individuals’experiences, which are often multi-dimensional andmulti-layered, whilst elucidating various aspects of theresearch topic. Braun and Clarke [32] have defined sixphases of conducting thematic analysis: familiarisingwith the data; generating initial codes; searching forthemes; reviewing themes; defining and naming thethemes; and report producing. Audio recordings of allinterviews were transcribed verbatim and the transcrip-tions were carefully read several times to become famil-iar with the data to obtain a holistic appreciation ofparticipants’ experiences. Salient words, phrases andsentences used by the participants were highlighted inthis phase. Participants’ statements or moments of ex-perience were then initially coded so as to capture theirideas. Next codes were collated into potential overarch-ing themes and sub-themes. In the fourth phase, alloverarching themes and sub-themes were then re-checked against the coded data extracts, as well as theentire original transcriptions and refined to ensure anauthentic reflection of the participants’ experiences. Thisphase necessitated a more focused analytical ordering ofthemes and subthemes. The next phase involved gener-ating definitions and names for each theme to tell theoverall story. The final phase of the data analysisconsisted of selection of vivid and compelling extractexamples, relating the analysis back to the researchquestion and literature. The first author carried out thedata collection and data analysis and other co-authorscontributed to study design, formulation of data analysisplan and interpretation of findings.

RigourAn in-depth face-to-face interview method was used toexplore individuals’ perceptions and beliefs towardsADHD and stimulant medication use in their own words.

Table 1 Demographic characteristics of the study participants

Total participants (n = 8)

Sex

Female 7

Male 1

Age group in years

20–40 2

41–60 6

Race

Caucasian 8

Country of birth

Australia 5

South Africa 1

United Kingdom 1

United State 1

Education attainment

Undergraduate 1

Graduate 4

Post graduate 3

Diagnosed with

ADHD 4

Depression 3

Had child/ren with ADHD

One child 3

More than one child 4

Had no children 1

Category of respondent

Mother 5

Father 1

Grandmother 1

Adult with no children 1

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Therefore, the research method was anchored in the con-structivist tradition to construct knowledge, meaning andunderstanding through human interactions, and so thetrustworthiness was ensured in the course of conductingthis study [33]. Rigour was also enhanced through famil-iarity with and continual immersion in the data at everystep before and during analysis [32]. The validity of indi-vidual overarching themes and sub-themes in relation tothe data set was ensured through continual revision andchecking of coded data extracts and transcriptions, indi-vidually and collectively, to reflect accurately the meaningsevident in the data as a whole [32]. Producing the researchfindings to tell the complex story of the participants’ per-ceptions and experiences was another way to ensure thevalidity of the analysis [32].

Ethics approvalThe study adhered to ethical principles according to theNational Health and Medical Research Council guidelinesfor conducting human research [34]. Ethical clearance wasobtained from The University of Western AustraliaHuman Research Ethics Committee (RA/4/1/2000). Aspart of this approval, each participant received a writtenparticipant information sheet, advising that participationwas voluntary and assuring the person that they could de-cline to answer any question that they felt uncomfortablewith and that they were at liberty to withdraw at any timewithout consequence. The anonymity of the participantswas protected by using pseudonyms.

ResultsThe analysis of the interviews revealed three overarchingthemes with two sub-themes for each. In sharing theirexperiences, participants touched on many commonthemes, yet sometimes these were in indirect contradic-tion to one another, demonstrating the complexity of thetopic. Collectively, the interrelated yet contradictoryperceptions and meanings were powerful drivers ofstimulant use and are illustrated in Fig. 1.

An impairment to achieving successIt’s a double-edged swordIn discussing their experiences the participants expressedtheir negative and positive views towards ADHD. Parentsreflecting on their experiences of their children suggestedthat children with ADHD were ‘difficult to manage’,‘challenging’, ‘exhausting’, ‘not normal’ and had some-thing ‘wrong’ in them. The parents stated that ADHDhad a profound impact on their children’s learningat school, and noticed ‘lack of concentration’, ‘strug-gling with school work’, ‘not achieving at school’ andhaving ‘no friends’. Some noticed an emotional rollercoaster in their children and one felt that her sonwas suicidal.

I didn’t realise that the emotional problem that [myson] was experiencing was direct result of ADHD. Iknew his hyperactivity was, but I didn’t know theemotional difficulties he had. I didn’t understand theimpact of ADHD he had. I just saw the hyperactivitything … struggling at school … but by the time he was15, things were coming apart and really I did worrythat he would suicide. (Jo)

As adults, participants described similar experiencesincluding ‘lack of concentration’, ‘unable to remainseated’, difficulties in ‘waking up in the morning’, ‘orga-nising tasks’, and ‘working with co-workers’.Despite the difficulties they experienced, as parents, the

participants often added positive attribution of their child’sADHD for higher physical energy levels and cognitiveabilities. Some believed that people with ADHD could behighly intelligent, and articulated that ADHD symptomscould be seen among famous people like ‘Aristotle’ and‘Einstein’ throughout history. Annette had two of herchildren diagnosed with ADHD, and she thought:

First it was a curse. It was so hard to control; it pullsthem so difficult, they torn of their different feelings[sic]. But other side some of the things they do areamazing. It is like a gift, having extra especial power,but whether you can control them?

Jo perceived a positive side of ADHD along with itsnegative connotation. She found her ADHD child wasfun:

He was intellectually challenging and fun to rear …interesting … creative so far out of the box … you haveto have eyes [in the] back of your head … never a dull

Fig. 1 Perceptions of ADHD and stimulant treatment choice. Theresults consisted of interrelated yet sometimes contradictory themesthat depicted the participants’ views of ADHD and stimulanttreatment, and in turn influenced the participants’ decision makingprocess to adhere to stimulant treatment

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moment … exhausting and emotionally scarring butincredibly interesting … intellectual stimulus … youcan put [it] that way.

Jo was also diagnosed with ADHD and taking medica-tions. She compared her life to her friends’ lives, anddescribed:

They [her friends’ lives] are organized and dull – myone is chaotic and fun. We see more funny connectionthan other people see – more interesting … one of myfriends said I was lot more fun before [treated].

She then added when she was asked about her percep-tion towards ADHD:

I think about this a lot and I’m not sure. We read alot about those outstanding individuals for whomADHD has been a blessing that they have made greatdiscoveries and they are enormously successful ….There was a belief that human clan would not succeedwithout ADHD people in the society … [but] the flipside of me says, the success stories that … you do nothear about people who had their life in hell because ofthe emotional difficulties that ADHD creates. My sonand I talked about this a lot. We both agreed [that]…the technicolour as we call the life we live is not worth,we prefer the black & white that everybody lives. So …it’s a double edged sword ….

It has to be fixedPredominantly, however, ADHD was viewed as a ‘prob-lem’ and a ‘disability’ that needs to be cured. Partici-pants frequently mentioned the impact of ADHDbehaviour on their child’s inability to ‘achieve’ at schooland ‘function properly’ in society. They believed aca-demic achievement is the key to success in life, andeverybody should strive for success. Participants per-ceived ADHD as an ‘impairment’ to achieving ‘success’.As Susan stated:

We need to fix the problem. If he is not achieving atschool what he is supposed to achieve and there is aproblem, then do whatever it needs to be done to fix it….

Kate’s perspective was similar:

We think ADHD is impairment to success. We thinksuccess is everything. You got to be successful in life,academically and financially successful. You need toachieve regular goals, family/wife/kids. So, this isimpairment, something to be cured … it has to befixed.

Diagnosis as a reliefIt’s not my fault‘Diagnosis as a relief ’ was the vernacular that all partici-pants expressed knowing that the condition was a ‘neuro-biological disorder’ caused by ‘missing chemicals in thebrain’, and so was not their fault. The diagnosis relievedthem from anxiety and stress, and provided reassurancethat they or their children were not ‘bad’ or ‘naughty’, ‘lazy’or ‘stupid’. The relief was also closely linked with the sensethat there is help available, as Cheryl expressed:

I was pleased to find out that there was something wecould do because my son was really struggling. So itwas very good for us to find out what the cause was ofhis problem … a big relief because he was clearlyintelligent but he was clearly struggling.

Linda described her feelings after she was diagnosedwith ADHD:

I actually felt relief. I was relieved because I realisedthat I was neither mad nor bad. There was certainlyevidence that made other people to feel that I was bad… sometimes I thought am I crazy? People said I amrude, I am this and that, I am mad … but I thought Ihad a good heart … I am concerned about people’swellbeing and I wanted to help…now I know why.

The diagnosis served parents as a mean of validatingtheir parenting skills. They felt relief from a burden ofguilt about being bad parents who could not disciplinetheir children. As Jo felt:

… relaxed, thankful, happy, probably validated. Alongthe way we tried couple of others because he [son] hadlearning difficulties despite his intellect, we had himtested various other types of psychologically tested.They said he had learning difficulties associated witheye sight tracking which is very common with ADHD… but he had two other diagnoses that both said thatI was an over protective mother that caused thosehassles… so I was causing his problem. They said Iwas the problem, not him … it was all my fault andhe had nothing wrong with it. So when he wasdiagnosed very comprehensively to fulfil more thanminimum criteria [for ADHD], or maximum whateveryou could have, it was a validation for him and forme. For him it was giving a name and understandingof why he was different.

All participants had a biomedical understanding ofADHD and recognised it as a medical condition, but,did not perceive this condition as a mental illness. AsFiona (grandmother) described her grandson’s ADHD:

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He is missing a chemical that doesn’t allow his brainto do what he needs to do. His brain is seekingstimulation or lacking the ability … it’s not an illness,but it’s a disability, because his body can’t do certainthings.

Kate acknowledged that according to diagnostic cri-teria – the Diagnostic and Statistical Manual of MentalDisorder [1], ADHD is a mental illness, but still she wasreluctant to believe that her son had a mental illness:

Well, ADHD is a mental health issue in the DSM 4and 5. According to that he has, but I don’t thinkabout it to be honest … I don’t see him mentally …but if not treated it can be a mental health issue…[so] we accommodate for his [ADHD], so he won’thave any serious mental health [problem].

While the participants were reluctant to accept ADHDas a mental illness, they accepted this condition as a dis-ability. It appeared that the disability status of ADHDmight serve some purpose for two of the participants.Annette who had two of her children diagnosed withADHD, found that school staff were supportive and theyunderstood ADHD as a disability, and accommodatedher children’s needs with special care as necessary. She,however, became “frustrated” with the social securitypersonnel who did not think of ADHD as a disabilityand so did not think Annette should be eligible for acaregiver allowance for children with disabilities. How-ever, Linda who did not perceive ADHD as a mentalhealth problem, but believed it as a disability, was ableto secure her disability pension for ADHD.

It runs in the familyThe relief was closely tied with perceiving ADHD as agenetic condition and realising that it ran in other familymembers. The participants mentioned that after onechild was diagnosed, they started noticing similar symp-toms in their other children and in other family mem-bers. Three of the participants were diagnosed after theirchildren were diagnosed. Patrick was one of them:

My two older boys were diagnosed first, and listeningto the paediatricians I realised that me and my wifehad the same symptoms … so it came through ourlines, therefore it was genetic and heritage ran from us… so we were treated.

Annette defended herself saying that she tried her bestto be a ‘good mother’ during her pregnancy and after-wards doing ‘everything right’ and confirmed thatADHD was not her fault but a genetic disorder.

When I was pregnant, I did nothing wrong – nodrinking, no drug, no bad food. I did everything by thebook. I pumped myself from everything to be the bestmother … since they were little I gave themboundaries, they were not allowed to have soft drinks,sugar … so, that was not the case … it [ADHD] wasfrom the family … it’s genetic, it’s through thegeneration … through the father … while doing this[treatment for the first child] we sort of knew myhusband had had it for a very long time. So we gothim diagnosed … it’s hereditary … since my husbandwas diagnosed, my father-in-law with full of ADHD …in his 60s … said to me “I know I’ve got it”.

ResponsibilityTo be normalResponsibility focused on parents’ abilities to solve theproblem their child was experiencing at school and howstimulant medications helped the parents to fulfil theirresponsibilities. When describing the effect of medica-tion, the parents and grandmother in the study placedemphasis on their child’s academic outcomes. The medi-cation helped their child to ‘slow down’ and to engage‘straight away’, which helped the child to ‘focus’, ‘concen-trate better’ and ‘stay on task’ at school. The parentsfrequently mentioned that their child achieved highergrades after taking medications. Three parents said thatthe school teachers were also happy with the change intheir child’s behaviour. For two parents, medicationswere believed to improve the ‘quality of life’ of the child.A few participants reported unpleasant effects of thestimulants, such as ‘mood swing’, ‘weight loss’, ‘decreasedappetite’, ‘heart going faster’ and ‘trouble with sleeping’.They mentioned that their child was prescribed‘Catapres’, which was usually prescribed for high bloodpressure, to reduce the side-effect of the ADHD stimu-lants. All parents acknowledged stimulants as the most‘evidence based’, ‘effective’ treatment. Four recognisedthe stimulant as an ‘important part’ of the ADHD treat-ment strategy, but as only ‘a part’, and said that theirchild also required psychotherapy, counselling, learningand behavioural management.All parents reported in initial hesitation about using

stimulant treatment, and expressed concern that themedication was ‘not good for health’. The grandmothermentioned that her initial resistance to medication wasdue to ongoing debate in the public sphere about over-diagnosis of and over-medication for ADHD. Twoparents exhausted other alternative therapies before theyagreed to stimulant medication. As Cheryl noted:

… it’s not the decision that parents make easily. Anylong term medication that you put your child on – thisis something you have to think about long and hard.

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You have to decide that your child is diagnosed withsomething; you have to be satisfied with … pros andcons. … We tried occupational therapy … all sorts ofthings and wasted lots of money … but when it wasclear that none of these were happening - it wasalready two years. Actually it was my biggest regretthat I didn’t try with the medication at the beginning.He would have learnt a lot more at school in thosetwo years.

Parents felt it was their responsibility to boost theirchild’s ‘self-esteem’ to make them feel ‘normal’, so thatthey could ‘fit in’ society. Annette felt ‘strange’ with theidea of giving medication to manage behaviour initially;however, she convinced herself, thinking that givingstimulants to her children for ADHD was similar to tak-ing blood pressure medication for herself. As such, sherealised that she must not feel guilty about giving theADHD medication, because it was her responsibility as a‘good mother’ to help her children to improve their self-esteem and to allow them to fit into the community. Asshe articulated:

I felt strange … but now it is a normal way of life andI don’t have a problem with it. So I don’t feel guiltyabout giving [medication] to them [the children]. As aparent, it is my responsibility to give them … it is nodifference to my blood pressure tablet. I have to takeblood pressure tablet or I would feel ill. … So, it’s[medication] a tool for them to cope. To me, it’s a toolto not feel inadequate, not feel different. I don’t wantthem to be in trouble. I don’t want them to feel thatthere was something wrong with them … it’s aboutself-esteem, confidence … about fitting in … learning,adaptation. … So they have their routine, and theyhave to take the medication every day to be normal.

In many instances within the interviews the partici-pants defended others’ perceptions of their ADHD be-haviour or that of their children. They took a proactiveapproach to educate people about the nature of ADHDand the role of medication. They tried to move beyondwhat other people perceived about themselves and alsoany feeling of guilt that troubled them about givingmedication to their child. They appeared to be justifyingtheir decision to adhering medication treatment. Theyadvocated for ADHD as a disability and the use of medi-cation as an acceptable treatment choice. They believedthat by educating others they would normalise ADHD,destigmatise stimulant treatment, and improve the out-comes of their and their child’s ADHD. Through thisrole, they constructed themselves and their child asnormal. Patrick and Cheryl took on the position ofeducators for managing ADHD and stimulant treatment.

Annette raised money for an ADHD charity. She andher husband, who was also diagnosed with ADHD,“proudly wear t-shirts writing on it – ‘ADHD makes mewith a super power’, ‘I’ve forgotten my meds today’ so that[their] kids have a role model”. Annette also workedhard to educate other parents and children about ADHDso that other children would find her children ‘normal’and ‘average’. As she described:

So, I try to make it open as much as possible. Ibrought the book, and the teachers read with otherkids that [her son’s name] has a brain, and he can’tconcentrate. So the whole class would know – that’show the teacher is educating the children. There isnothing wrong with [her son’s name], he has takenmedication to calm down. So if the parents think thatway, it should come from the children that [herson’s name] is not naughty, not a bad kid and hedoes not have any problem. I used to bring allbooks and DVD on ADHD and gave it to teachersto give it to other parents, because I wanted tohave others to be educated.

To fit inSusan also expressed her concern about giving medicationto her child, but she justified her decision by saying thatas a ‘responsible mum’ it was her duty to make her son fitinto school and, therefore, she needed to continue withthe medication. To minimise the harm of the medicationand to allow her son to ‘learn to be himself ’, she gave hima break from medication on school holidays.

I feel I am doing the right thing, but I wish I didn’thave to … I don’t like it [giving the medication], but Ihave to do it for his education. It’s a drug and it is notgood for your body, … so on school holidays I don’tgive it to him, he doesn’t need it for any reason,because he is what he is, so he can learn to be himselfwithout the pill … but he has to go to school and dowhat he is told to do and to fit in. If he was diabetic,he had to have the medication. So I feel to be aresponsible mum, he has to have it. I can’t have himthe way he wants to be … that’s not responsibleparenting … that’s wrong … giving him wrongexpectations – so he has to take the pills …responsibility is you have to do what you have to do. Ifhe is happy with his life later not to take it that wouldbe his adult decision, [but] I will guide him until then.

Susan, however, did not get her older son, who shethought also had ADHD, diagnosed and treated, becausehis condition was not affecting his education. Shethought because he was ‘getting away with his schoolwork’, she did not need to ‘medicate’ him. Through

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comparing ADHD medication to that taken for chronicdiseases, such as diabetics or blood pressure, the parentsemphasised the medication’s role in their child’s future –perceiving it as an investment for their child’s academiccareer, despite giving medication being an unpleasantfeeling for them. Thus, they constructed themselves as a‘good parent’ which allowed them to resolve any feelingsof guilt about giving medication.For the adults with ADHD, taking medication was also

about a responsibility to ‘fit in’ at work, within familyand in relationships. They experienced improvement onevery day activities, organising tasks at work, interper-sonal skills and having meaningful conversations like‘normal people’. They found their family and friendscoped better with them when they were on medication.As such it was their responsibility to fit in with familyand society. As Susan, who was also taking medicationfor ADHD, reflected:

I take my pill to cope with pressure … I could copewith the world … if I didn’t take the pill I wouldn’t beable to talk to you like this … wouldn’t be able to focusat work … my husband copes better with me when Iam on the pill … so I have to [take medication], tostay in the relationship, to keep our life easy.

DiscussionThe findings of this exploratory study assist in under-standing the complexity of ADHD. The results consistedof interrelated yet sometimes contradictory themes thatdepicted the participants’ views of ADHD and stimulanttreatment. There were three overarching themes: an im-pairment to achieving success, diagnosis as a relief andresponsibility. The findings from this study reflect theontological and epistemological assumptions of thesocial constructivist framework [35], which assumes thatacross individuals there may be multiple understandingsof phenomena, being in this instance ADHD andattitudes towards its treatment with stimulant medica-tion. It was notable that the themes were defined andredefined by the participants particularly throughtheir everyday interactions with others in a commu-nity setting.ADHD is perceived to be an impairment to achieving

success reflected in two sub-themes: ‘it’s a double-edgedsword’ and ‘it has to be fixed’. The expression ‘double-edged sword’ in this study bares similarity to observa-tions made in a UK study, where Singh et al. [36] notedthat young people with ADHD expressed a dichotomoussense of themselves. They felt that their ADHD behav-iour was ‘fun’, but then acknowledged that their funbehaviour was ‘annoying’ to others. The participants inthis study perceived ADHD as fun, challenging and in-teresting; however, when comparing the fun behaviour

with the perceived obstacle to achieving success, andparticularly academic success, they chose to acceptADHD as an impairment which had to be ‘fixed’.The participants had a biomedical understanding of

ADHD, ascribed to it a causal relationship with aca-demic under performance [37] and accepted stimulantmedication as the eventual treatment of choice, albeitsometimes after seeking alternatives or as the mainstayof a broader treatment strategy. This was in line with ahelp-seeking behaviour model for ADHD, whichsuggests that the individual’s perceptions about ADHDinfluence their treatment choice [38]. Our findingsresonate with those from Canada, where Johnston et al.[39] identified that people’s degree of acceptance of amedical aetiology of ADHD was significantly associatedwith stimulant treatment choices. The participants inthis study were Caucasians, relatively affluent and welleducated. Understanding ADHD as a medical conditionand accepting stimulant treatment to improve academicperformance is comparatively more common amongCaucasian families than in other ethnic groups in the USand UK [6, 40]. However, when a child’s academicachievement seemed to be threatened by ADHD, peoplefrom other cultural and ethnic background were alsofound to accept stimulant treatment. Korean parentswho tended to take personal responsibility for theirchild’s ADHD behaviour and had initial negative atti-tudes towards medication treatment, were reported toadminister stimulants once they believed that ADHDwas associated with their child’s relative lack of academicachievement [41]. In a study in India, the findingssuggested that parents who resisted a biomedical explan-ation of their child’s ADHD behaviour tended at first toseek religious help to minimise the impact of the ADHD.The same parents, however, sought medical interven-tions when they perceived that problems with theirchild’s academic performance were not improving [42].Participants in this study described a sense of relief

following diagnosis, as it provided them with an explan-ation for the difficulties they or their child had experi-enced. The sense of relief stemmed from the fact thatthe diagnosis reassured them that the problem behaviourwas not a personal failing in any moral sense, but rathera mental or at least cognitive disorder. In a phenomeno-logical study of eight adults with ADHD in the UK,Young et al. [43] also reported that the diagnosis elimi-nated an individual’s sense of failure as their ADHDbehaviour could be explained and attributed to a specificdisorder. The parents in this study tended to defendthemselves, saying that they did their best to be ‘good’parents and so the parenting was not the cause of theirchild’s ADHD. As such, the diagnosis validated thechild’s problem behaviour and school failure what not areflection of failed parenting. These findings have

Ghosh et al. BMC Health Services Research (2016) 16:141 Page 8 of 12

parallels in another study by Singh [44], conducted inthe UK and US among 153 children and their parents,for whom the diagnosis provided a great relief. Parents(mothers especially) with an ADHD child often walk a fineline between perceiving themselves as ‘good’ and ‘bad’ par-ents, because they are most often blamed for their child’smisbehaviour and under achievement [45–47]. Hence,scholars argue that although parents use the biomedicalmodel of aetiology of ADHD to provide some relief fromparental blame, the medical model may not serve to pro-vide total relief from feelings of personal responsibility,stress, anxiety and guilt [44, 48]. As Taylor et al. [24] notedin an attempt to make the right decision for their childabout the stimulant treatment, parents go through severalstages in which they face contradictory societal attitudes,such as parental blame for their child’s misbehaviour onone hand, while also experiencing anxiety and guilt feelingabout drugging children by administering stimulants. Tocope with the stressors of raising ADHD children and theassociated societal pressures, parents tend to defendthemselves by employing strategies like advocacy, educa-tion and strategic difference [49], all of which are congru-ent with the findings from this study.Parental concern about the potential long-term side

effects of stimulant medication was observed in anotherstudy in the US, where parents of children with ADHDexpressed fears and accepted stimulant treatment reluc-tantly, even though they agreed that the medicationhelped their child [50]. Despite being worried aboutlong-term effects and some immediate unpleasant side-effects of stimulant medication, parents in this study feltthat it was their responsibility to continue with themedication to improve their child’s self-esteem by help-ing the child feel normal and to ‘fit in’ with the commu-nity. Whilst results have been reported where parentsdiscontinued stimulant treatment in their child’s bestinterest due to uncertainty about long-term effects onbrain function, related stigma and the child’s disliking ofuse [51], the present findings are more consistent withthose of Hansen and Hansen [48], who found that par-ents tolerated the medication’s side effects and risks inthe hope that it would play an important role in enablingthe child to attain their academic goals and achieve suc-cess in their adult life.Parental effort to improve their child’s academic per-

formance and boost self-esteem is a rational conse-quence of the fact that higher education is a critical pathto one’s career success in modern society [52, 53]. Toachieve career success, an individual is required todevelop competency across a wide range of personalqualities, which may include self-esteem [54, 55]. Whilesome investigators have found no influence of self-esteem on relationship or career success [56, 57], othersclaim that a high level of self-esteem is crucial for

success and life satisfaction in these spheres [58–60].Whether one’s self-esteem serves career success or not,self-esteem is valued in today’s society [61], and develop-ing children’s self-esteem is reportedly evident as acornerstone of contemporary Western parenting prac-tices, particularly in middle class families [62]. In aqualitative study using semi-structured interviews withCanadian parents of children seen as cognitively im-paired (including some with ADHD and learning disabil-ities) and those with unimpaired children, Ball andWolbring [22] found that parents would consider stimu-lant use if they perceived their child was struggling atschool, failing to fit in or had low self-esteem. The par-ents in their study believed that it was their responsibil-ity as good parents to make their child feel normal andencourage them to succeed in life.The adults diagnosed with ADHD in this study also

referred to their needs to feel ‘normal’, to have the abilityto interact with other people, to belong in the commu-nity and to be accepted by family and friends. Thesefindings are consistent with other studies where adultswith ADHD perceived that being accepted by others as anormal, responsible social being was important [43, 63],and that the medication enabled a sense of normalityand social belonging to occur [43, 64].The findings from this study suggest that individuals’

perceptions and experiences shared much in common inthe general sense, yet in detail the individuals’ journeyhad been diverse and complex. The findings underlinethat a person’s understanding of ADHD behaviour andtheir attitude towards stimulant treatment are importantconsiderations in selecting an appropriate interventionand in developing policy on the regulation of stimulanttreatment use. Individuals who do not experience theperceptions of difficulties in academic performance orfitting in with society may not necessarily seek stimulanttreatment, even if it would be beneficial from an object-ive viewpoint. This was noted in the interview withSusan, who thought that her older son also had ADHD,but did not seek treatment for him because he wasachieving school grades to her satisfaction. On the otherhand, desire to accelerate academic performance maymotivate individuals to pursue the non-medical use ofstimulants [65, 66]. Parents were hesitant to use stimu-lant medication initially due to long-term side effects,but administered it as they were concerned about theirchild’s academic under performance, self-esteem or fail-ing to be ‘normal’. More parents may consider stimulantmedication if they perceive these drugs as less harmfulor if cultural trends redefine what is normal.This study contributes to the body of literature with its

focus on individuals’ perceptions of ADHD and attitudestowards stimulant medication, including perceived roles ofmedication in child’s future. Paying attention to perceptions

Ghosh et al. BMC Health Services Research (2016) 16:141 Page 9 of 12

of ADHD and reasons for seeking or not seeking stimulanttreatment is important when planning appropriate inter-ventions for this condition to avoid over-diagnosis andovertreatment. The findings reinforce the need for moreeducation of medical professionals to enable them to planappropriate interventions and to give appropriate supportand guidance to optimise outcomes for individuals withADHD and their families.There are some limitations to this study that deserve

consideration. Firstly, the participants were white, mid-dle class people, living in a metropolitan area. As such,their perceptions may not reflect those of communitymembers from other backgrounds, highlighting the needfor research among culturally, ethnically and socioeco-nomically diverse groups in the future. Secondly, as thesample was largely female, the views of a wider range ofmales were somewhat absent from the research. Thirdly,three of the four adults with ADHD were parents whowere diagnosed after their children had been diagnosed,and mostly described their experience as being parents.Even though the experience of one adult with no chil-dren was little different from the parents diagnosed withADHD, findings drawn from this sample may not betransferrable to the perceptions of ADHD and stimulanttreatment of adults diagnosed with ADHD. Fourthly,given the nature of qualitative analysis, this study repre-sents only one interpretation of the participants’ experi-ences, hence it delivers a partial, static picture of theirperceptions of ADHD behaviour and attitudes towardsstimulant treatment. Further, the analysis primarily de-notes interpretations made by a single research groupwith the possibility that others might draw different in-ferences. Despite its limitations, this study does providesome important data with respect to the factors thatshape individuals’ attitudes towards ADHD and influ-ence individuals’ treatment choices. Building on theseinsights, further research can be conducted in a formatthat would canvas a wider range of views. Future re-search could also include a multi-perspective and longi-tudinal design, interviewing children, young adults andtheir parents to explore evolving perceptions of ADHDand medication over time.

ConclusionThe participants in this study perceived ADHD behaviouras an impairment to achieving success in life. A desire foracademic achievement, good self-esteem, being normaland a sense of belongingness were important drivingforces for stimulant treatment use among parents of chil-dren diagnosed with ADHD. Adults diagnosed withADHD found stimulant medication was important for aresponsible person to fit in to the community. The find-ings have potential to be used to raise awareness andunderstanding among medical practitioners working with

ADHD adults, children and their parents of the perceivedreasons why individuals seek or do not seek stimulanttreatment.

Availability of data and materialsIn accordance with the Human Research Ethics Com-mittee, University of Western Australia (HREC-UWA)protocol, research data involving human participantscannot be made available to the public for confidentialityand ethical reasons. Demographic and interview ques-tions are included as an additional file.

Additional file

Additional file 1: Demographic and Interview Questions. (DOCX 36 kb)

AbbreviationsADHD: Attention Deficit Hyperactivity Disorder; WA: Western Australia.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsMG and CDJH participated in the study design and formulation of dataanalysis plan. MG carried out the data collection, data analysis of the study,and prepared the initial draft of the manuscript. CF was involved in thetheoretical framework and helped interpret findings. DBP critically revisedthe manuscript for intellectual content. All authors reviewed the draft,contributed to the discussion and approved the final manuscript.

AcknowledgementsManonita Ghosh was the recipient of the Australian Postgraduate Award(S19655873). We express our gratitude to all the participants who mustremain anonymous.

Author details1Centre for Health Services Research, School of Population Health, TheUniversity of Western Australia, 35 Stirling Highway, Crawley, WA 6009,Australia. 2School of Population Health, The University of Western Australia,35 Stirling Highway, Crawley, WA 6009, Australia.

Received: 23 October 2015 Accepted: 12 April 2016

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